HomeMy WebLinkAboutKing Arthur Way #11 - 8/1/1997MANSFIELD BOARD OF HEALTH
APPLICATION FOR PERMIT TO DRILL WELL
Name lJ
Address ✓ nft',-14,12
Locationi1l,S
r
Registered
Well Driller 4,41iJ l ,S?,Q19`J1,z,<-1L C.0, _;'/ G
Address e 200 /tlS t Z dE1 u C
TYPE OF WELL:
_Domestic Potable (for household use)
Domestic Auxiliary (for watering, pools, etc.)
_Industrial/Commercial Potable (for human consumption, including food processing)
—Industrial/Commercial Auxiliary (for manufacturing, etc.)
_Agricultural (for irrigation of land in the business of agriculture)
Fee: Domestic $ 10.00 _In-lustrial/CommercialA I00.00 N/C Agricultural
Date: C `off � �' 1` Applicant Signature:
PERMIT TO DRILL A WELL
The above application has been approved and permission is granted to drill a well for the
following use at Fj #t,' (J
D mestic Potable (for household use)
mestic Auxiliary (for watering, pools, etc.)
—Industrial/Commercial Potable (for human consumption, including food processing)
—Industrial/Commercial Auxiliary (for manufacturing, etc.)
_Agricultural (for irrigation of land in the business of agriculture)
t
Date: ` -j Approved by: ✓ ..
or the Board of Health
NOTE: Electrical permit required, underground cable trench must be inspected
Upon installation of well, call Department of Public Works office at
261-7331 to be added to well list.